Contributors AN conceived the study, performed most of the dissection and drafted the manuscript. PA aided with the dissection and compiled
the results.

Accepted 4 April 2012

Published Online First 5 May 2012

Abstract

Objective Apart from case reports and anecdotes, there are no published studies on the feasibility of using non-medical devices for
emergency bystander cricothyroidotomy. This study evaluated the ability of non-trained junior doctors and medical students
to place an emergency cricothyroidotomy on an embalmed cadaver using only a blade and a ballpoint pen.

Methods Participants were junior doctors with no prior experience of surgical airways and second year medical students at the end
of their head and neck anatomy course. Nine participants were asked to place an emergency cricothyroidotomy in an undissected
embalmed cadaver using only a No 26 scalpel and a dismantled ballpoint pen (Papermate Flexigrip Ultra, external diameter 8.9 mm;
internal diameter 7.0 mm). Times were recorded and direct visualisation by dissection was used to assess placement and complications.

Results Nine participants performed a total of 14 separate cricothyroidtomies on separate cadavers. Landmarks were palpable by researchers
in 10 of the 14 cadavers. Eight of 14 (57%) procedures were deemed successful. No major vascular injury occurred. Injuries
to the thyroid and cricoid cartilages were common; four of 14 (29%) of these injuries were fractures.

Conclusions In embalmed cadavers, inexperienced junior doctors and medical students with no prior training were able to place a successful
cricothyroidotomy slightly more than half the time. It suggests that surgical cricothyroidotomy with a ballpoint pen and blade
is a feasible option in extremis. It is unknown whether junior doctors from other specialties, such as emergency medicine,
would perform better.